Prevalence of obstructive cholangitis in patients presenting with jaundice and factors

Aim: Acute cholangitis is a clinical emergency which has to be treated as soon as posibble. First, the general situation of the patient is evaluated. Then, the following steps for treatment are antibiotics and biliary drainage. There are no internationally accepted standards for treatment by antibiotic regimens. This is because, microorganism profile shows a different regional distributions and resistance patterns. In our study we try to define the acute cholangitis frequency in biliary obstruction and to determine the microorganism profile and biliary drainage and antibiotics in acute cholangitis. We also try to evaluate the importance of physical examination, laboratory tests for the diagnosis of acute cholangitis. Methods and Materials: A total of fifty-one patients with a history of biliary obstruction were included into the study between November 2013 through June 2014. Physical examination, Laboratory tests, complete blood count, liver function tests, tumor markers, and acute phase reactants for inflamation were studied. A at least one display of all of the patients' USG (ultrasonography)/CT (computed tomography)/MRI (magnetic resonance imaging)/MRCP (magnetic resonance kolanjio pankreotograf) is provided. The bile samples were taken via ERCP (endoscopic retrograde kolanjio pancreatography). Blood cultures of patients who had fever were taken during the clinical follow-up via appropriate techniques. All the applied antibiotic regimens and the ERCP findings were recorded. Results: Fifty-one patients; 28 female (54.9%) and 23 male (45.1%) were included into the study. The average age of the patients was 56.5±18.2 years old. According to Tokyo Guide (TG13), (clinical signs, CRP (C-reactive protein), and the appearances of other inflammation markers were observed in 19 patients (37.3%) with acute cholangitis clinic. The Charcot triad (fever, icterus, and abdominal pain) were evaluated for all patients included in to the study. Patiens were divided according to the presence of acute cholangitis or not. The patients who had acute cholangitis had fever (p=0.0001), icterus (p=0.045), tachycaria (p=0,008), antibiotic treatment history (p=0.008) and fever seniation (p=0.0001) significantly higher than the other group. The Charcot triad was positive in 7 (36.8%) of the patients with cholangitis. Althouh the positivity ratio is 36.8%, presence of Charcot triad increases the acute cholangitis risks 18 times. The patients who had acute cholangitis had significantly higher levels of CRP (p=0.005), Procalcitonin (PCT) (p=0.008), and lower levels of hematocrit (HCT) (p=0.0001). The bile smaples were taken from all patients. 39 patients (76.5%) had positive cultures, 15 patients had fever during clinical follow-up, and 4 (26.6%) of them had positive blood cultures. As for patients with acute cholangitis, 15 of them (78.9%) had positive bile cultures, 4 of them (21.1%) had positive blood cultures. Thirty of the bile cultures (76.9%) were found polymicrobial while 9 of them (23.1%) were found monomicrobial cultures. The microorganism profile was not found statistically different from acute cholangitis patients and the others, also blood and bile cultures were not shown statistically different microorganisms profile. In both groups, the bile and blood cultures reproduced microorganisms; 20 (39.2%) escherichia coli, 18 (35.3%) enterococcus, 14 (27.5%) pseudomonas, 13 (25.5%) klebsiella, 8 (15.7%) streptecoccus, 3 (5.9%) staphylococcus, 2 (3.9%) citrobacter, 1 (2%) acinetobacter, 1 (2%) proteus, 1 (2%) sphingomonas, 1 (2%) aeromonas, 1 (2%) gemella and 2 (3.9%) candida respectively. The microorganisms isolated from bile were 3(75%) escherichia coli, 1 (25%) klebsiella, 1 (25%) pseudomonas, 1 (25%) acinetobacter. If the microorganisms classified as gram positives and gram negatives,the sensitive antibiotics were tigecycline and vancomycine for gram positives and amicasin and colistine for gram negatives. The resistance were seen mostly for ceftriaxone in gram positives and for ceftriaxone and tigecycline for gram negatives. All the patients who had cholangitis were provided with biliary drainage and 17 of them (89.5%) received antibiotics. Two of them died because of cholangitis. Twenty-four of 32 patients (75%) without cholangitis had positive bile cultures and 17 of them (53.1%) received antibiotics and drainage at the same time. One of these patients died because of gastrointestinal bleeding. The other patients were released without any problem. There was no statistical differance between drainage or drainage +antibiotic tratment. Discussion: The biliary obstruction does not mean cholangitis in every patient. The Charcot triad is an important physical parameter which shows acute cholangitis. The bile culture positivity does not correlate everytime with acute cholangitis. Gastrointestinal contamination was an important factor for these contaminations. Biliary drainage performed by ERCP is a reliable method for the treatmentof cholangitis. Key Words: Cholestasis, Acutecholangitis, Choledocholithiais, ERCP